How Do Doctors Treat ‘Aggressive’ Prostate Cancer like Joe Biden’s?

How Do Doctors Treat ‘Aggressive’ Prostate Cancer like Joe Biden’s?

By Clara Moskowitz edited by Dean Visser

Former president Joe Biden has been diagnosed with prostate cancer, his office announced on Sunday. The 82-year-old has what is described as an “aggressive form” of cancer that has already spread to his bones. Though his disease is serious, there are promising treatment options, and Biden could potentially live for years with the diagnosis.

What is a Gleason score, and what does Biden’s mean?

Biden has a Gleason score—a benchmark ranking of prostate cancer severity—of 9 out of 10, his office revealed. This puts him in a category called Gleason Grade Group 5. The numbers represent the proportion of prostate cells that look malignant rather than normal under a microscope; a higher number represents a more serious, faster-spreading cancer. Biden’s score suggests that a large portion of his cells look abnormal and that his cancer is relatively high-risk: “He has the most aggressive Gleason pattern,” says oncologist Marc B. Garnick, a professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston.

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In Biden’s case, the cancer has already become metastatic, meaning it has moved beyond its origin point in the prostate and reached his bones. “Unfortunately, I’d say it is a very serious condition when prostate cancer spreads outside of the prostate and goes to distant places like the bone,” says Peter Nelson, vice president of precision oncology at the Fred Hutchinson Cancer Center in Seattle and head of the prostate cancer research program at the Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium. “Essentially it’s not a curable cancer.”

Just how serious the situation is depends on the details of the cancer’s spread to the bones. “The critical question is: How many bone metastases does he have, and what is the anatomic location of the metastases?” Garnick says. “This is a situation where the devil is in the details.”

What are Biden’s treatment options?

The treatment for Biden’s form of cancer, called metastatic hormone sensitive prostate cancer, is likely to be what’s known as doublet therapy—a combination of two drugs that target the production and activity of testosterone. This hormone is key to the situation because it fuels the growth of prostate cancer cells. Its active form, called dihydrotestosterone, interacts with a cell part called the androgen receptor. This receptor then tells the cell to proliferate and grow.

Biden could possibly be prescribed a drug such as leuprolide (Lupron) or relugolix, both of which shut off the signal in the brain that tells the testicles to make testosterone. In addition, he’ll probably take a second drug, such as apalutamide, enzalutamide, darolutamide or abiraterone. These agents inhibit the cells’ androgen receptors to block the action of testosterone.

The drugs, taken as a combination of injections and pills, can work together to shrink the prostate gland and bone lesions. If Biden responds well to the treatment, it’s likely that he won’t need chemotherapy.

“I would say he has a more than 90 percent chance of responding to the treatment and likely has at least several years of predicted response to that therapy,” Nelson says. “The problem is: it’s not a cure, and eventually the prostate cancer becomes resistant to that type of therapy.” This treatment can also lead to side effects such as loss of muscle mass and strength, deterioration of bone health and metabolic effects. “Testosterone is a very important hormone for men, so when you suppress it, you can have these side effects,” Nelson adds.

Still, Biden’s prospects are much more promising than they would have been even a decade ago, thanks to advances in treatment research. “In the past, the median duration of survival of someone presenting with bone metastases [from] prostate cancer was two and a half years,” Garnick says. “We now have patients living five, 10 and 15 years because of the new modalities available.”

What else can doctors do?

In addition to prescribing hormone therapy, Biden’s doctors will likely test the former president’s tumor to see if he has any mutations in certain cancer genes that would suggest specialized treatments were called for.

For instance, some prostate cancers end up being genetically linked to other cancers such as breast and ovarian cancer, through the presence of the genes BRCA1 or BRCA2. “Those are genomic abnormalities that can exist that can increase the likelihood of prostate cancer,” Garnick says. If that’s the case for Biden, he could receive specific drugs, such as poly (ADP-ribose) polymerase, or PARP, inhibitors, that target the type of prostate cancer he has.

How bad is prostate cancer in general?

Prostate cancer is among the most common forms of cancer in older men. The American Cancer Society estimates there will be about 313,780 new diagnoses of the condition and 35,770 deaths attributed to it in the U.S. in 2025.

“It’s not surprising that a man in his 60s to 80s would have a diagnosis like this—[prostate cancer] affects one in eight men in the U.S.,” Nelson says. “The ironic part is: Biden did so much to emphasize the importance of biomedical research in addressing our cancer burden. But he should benefit from that investment in making improvements in understanding cancer and how we can better develop therapies for it.”

Biden’s successor, President Donald Trump, has shifted course since beginning his second term. His administration has made significant cuts to funding for cancer research and has eliminated thousands of jobs in the Department of Health and Human Services, including hundreds of employees at the National Institutes of Health, the world’s largest funder of cancer research. “My plea is not to turn our back on the tremendous progress that’s being made,” Nelson says. “We still have a long way to go because we’re not curing advanced prostate cancer, even though we’re extending men’s lives. We still need major investments in biomedical research to develop true cures.”